MedicareBlue Rx a stand-alone prescription drug plan 2018 Step-by-step enrollment guide MedicareBlue SM Rx (PDP) S5743_090716_B04_RE CMS Approved 09/07/2017
Thank you for considering MedicareBlue Rx to serve your prescription drug needs! What is MedicareBlue Rx? MedicareBlue Rx is a stand-alone prescription drug plan that can pair with your medical plan to help manage your prescription drug costs. Conveniently fill your prescriptions at one of our nationwide network pharmacies. You may pay less when you use a pharmacy that offers preferred cost sharing. Why MedicareBlue Rx? Convenient: Fill your prescriptions at more than 67,000 pharmacies nationwide, with more than 36,000 of those offering preferred cost sharing. Or, fill your 90-day supply through our mail order service. Flexible: This plan offers a $0 deductible on Tier 1 and Tier 2 drugs. In addition, you may have lower copays or coinsurance if you use pharmacies that offer preferred cost sharing. A brand you know: MedicareBlue Rx shares the cost of medications you take today and those you may need in the future. What are my next steps? Follow this three-step guide to an easy and informative enrollment process with MedicareBlue Rx. 1. Review plan highlights 2. Use our online search 3. Determine your eligibility and enroll now Ready to enroll now? Enroll online at YourMedicareSolutions.com Call 1-866-434-2037, 8 a.m. to 8 p.m., daily, Central and Mountain Times (TTY hearing impaired users call 711) Contact your licensed sales representative Fill out the included enrollment form and mail it in the pre-paid envelope Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments and restrictions may apply. This information is not a complete description of benefits. Contact the plan for more information. The formulary and pharmacy network may change at any time. You will receive notice when necessary.
1 Review plan highlights Review the plan costs below. Refer to the Summary of Benefits for more information on plan benefits. MedicareBlue Rx plan overview The chart shows how much you will pay for your monthly premium and your cost share. Cost sharing may change when you enter another phase of the Part D benefit. Benefits MedicareBlue Rx Standard MedicareBlue Rx Premier Monthly plan premium amount you pay Annual deductible amount you pay before initial coverage begins Initial coverage amount you pay for a 30-day supply Tier 1: Preferred Generic drugs Tier 2: Generic drugs Tier 3: Preferred Brand drugs Tier 4: Non-Preferred drugs Tier 5: Specialty drugs Coverage gap amount you pay for a 30-day supply after your total yearly covered prescription drug costs reach $3,750 1 Generic drugs Brand-name drugs Catastrophic coverage amount you pay for a 30-day supply after you have paid $5,000 in out-of-pocket prescription drug costs 2 $37.40 $100.60 $0 on Tier 1 (Preferred Generic) and Tier 2 (Generic) drugs; $405 on Tier 3 (Preferred Brand), Tier 4 (Non-Preferred drug) and Tier 5 (Specialty) drugs Preferred Cost Sharing After you pay the applicable deductible $1 copay $5 copay 17% coinsurance 30% coinsurance 25% coinsurance 44% of the plan s costs 35% of the plan s costs Standard Cost Sharing After you pay the applicable deductible $15 copay $19 copay 21% coinsurance 41% coinsurance 25% coinsurance Preferred Cost Sharing $0 copay $0 copay 17% coinsurance 45% coinsurance 33% coinsurance $0 copay for Tier 1: Preferred Generic drugs, $0 copay for Tier 2: Generic drugs $0 Standard Cost Sharing $15 copay $20 copay 25% coinsurance 50% coinsurance 33% coinsurance $15 copay for Tier 1: Preferred Generic drugs, $20 copay for Tier 2: Generic drugs 44% of the plan s costs for all other generic drugs 35% of the plan s costs for all other brand-name drugs The greater of $3.35 copay for generic drugs and $8.35 copay for all other covered drugs OR 5% coinsurance 1 Your total drug costs means the total amount you have paid for covered drugs plus what the plan has paid for the calendar year. This does not include the plan premium you pay. 2 Your out-of-pocket costs means the amount you have paid for covered drugs for the calendar year. This does not include the amount the plan has paid or the plan premium you pay. 1
2 Search online Understanding your pharmacy network and drug tiers Using the formulary, also known as a drug list, and the pharmacy directory will help you get the most out of the plan s benefits. Price drugs Locate a pharmacy All prescription drugs are placed on tiers or different levels. Pharmacies in the network offer either standard or preferred cost sharing. The formulary will tell you which tier your medication is on. Whichever tier your drug is on will determine your share of the cost. Access the most current formulary at YourMedicareSolutions.com/drugs Nationwide pharmacy network With more than 67,000 in-network pharmacies throughout the United States, it s convenient and easy to fill your prescriptions. There are more than 36,000 pharmacies offering preferred cost sharing nationwide, including CVS/ Target pharmacies, Hy-Vee, Costco and many more. Tip: How to find a preferred pharmacy Look for pharmacies marked with a P in the pharmacy directory. These pharmacies offer preferred cost sharing. 2 You will usually pay the least amount if you use a pharmacy offering preferred cost sharing. Access the most current directory at YourMedicareSolutions.com/pharmacy
3 Determine your eligibility and enroll now Who is eligible to enroll? Regardless of your income or health, you can enroll in MedicareBlue Rx if you meet the below criteria. You are 65 or older, or are under age 65, and meet requirements. You currently have Medicare Part A and/or Medicare Part B. You live in the service area Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota or Wyoming. You are a U.S. citizen or lawfully present in the United States. When can you enroll? Initial Enrollment Period is the first time you can enroll. It is the seven-month period that begins three months before you first become eligible for Medicare. Annual Enrollment Period is when you can enroll or switch plans from October 15 to December 7 with changes effective January 1. Medicare Advantage Disenrollment Period is the 45-day period from January 1 to February 14 each year. During this time, you can disenroll from a Medicare Advantage plan and enroll in Original Medicare and a stand-alone Part D plan. Special Enrollment Periods allow you to enroll at other times of the year if you: How do I enroll? Refer to the inside cover page for easy ways to enroll in MedicareBlue Rx. Or, fill out the paper enrollment form included in the pocket in the back of this booklet, place it in the envelope (no stamp necessary) and mail it to us. What are the next steps? Once you have enrolled, look for the following items in your mailbox: Acknowledgment letter: We will send you an acknowledgment letter to confirm that we have received your enrollment request. Confirmation letter and member ID card: We will send you a confirmation letter and your MedicareBlue Rx ID card. These items will inform you of your effective date of coverage. Welcome Kit: You will also receive a new member welcome kit which includes a member handbook, a Formulary (drug list), an Evidence of Coverage booklet, mail order pharmacy form, and other important documents. Enroll now! YourMedicareSolutions.com Enter into or out of the plan s service area Lose coverage from an employer or union group plan, or Medicaid, or your current plan is no longer offering coverage Have other special circumstances Contact MedicareBlue Rx if you have questions. 3
Thank you for considering MedicareBlue Rx to serve your prescription drug needs! Easy ways to enroll Enroll online at YourMedicareSolutions.com Call 1-866-434-2037, 8 a.m. to 8 p.m., daily, Central and Mountain Times (TTY hearing impaired users call 711) Contact your licensed sales representative Fill out the included enrollment form and mail it in the pre-paid envelope Extra help for those who need it You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: 4 l> 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048 24 hours a day, seven days a week l> The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Eastern Time, Monday through Friday, TTY users call 1-800-325-0778 l> Your State Medicaid office
MedicareBlue SM Rx (PDP) is a Medicare-approved Part D sponsor. Enrollment in MedicareBlue Rx depends on contract renewal.coverage is available to residents of the service area and separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.* * Independent licensees of the Blue Cross and Blue Shield Association This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The formulary and pharmacy network may change at any time. You will receive notice when necessary. For more information Visit YourMedicareSolutions.com Call 1-866-434-2037, 8 a.m. to 8 p.m., daily, Central and Mountain Times (TTY hearing impaired users call 711) Contact your licensed sales representative For information about Medicare 1-800-MEDICARE (1-800-633-4227) TTY hearing impaired users call 1-877-486-2048 24 hours a day, seven days a week RAS1001R10 (09/17)